National Health Mission: Comprehensive Healthcare for All

India’s healthcare journey over the past two decades has been shaped by one ambitious mission that aimed to bring quality medical care to every doorstep, whether in a remote tribal village or a crowded urban slum. The National Health Mission (NHM) represents the country’s most extensive public health programme, weaving together rural and urban healthcare under a single, well-coordinated framework. Understanding how it functions reveals much about how India tackles its most pressing health challenges, from maternal mortality to malnutrition to communicable diseases.

What is the National Health Mission? 🔗

The National Health Mission was launched by the Government of India in 2013, bringing together two existing initiatives: the National Rural Health Mission (NRHM), launched in 2005, and the National Urban Health Mission (NUHM), launched in 2013. This consolidation created a unified framework aimed at delivering universal access to equitable, affordable, and quality healthcare services that are accountable and responsive to people’s needs.

The mission operates under the Ministry of Health and Family Welfare and is headed by a Mission Director, with National Level Monitors appointed to oversee implementation. Its scope is enormous, covering everything from primary care in remote villages to specialised services in district hospitals, with a particular focus on vulnerable populations including women, children, the poor, and residents of urban slums.

The two sub-missions 🔗

NHM functions through its two sub-missions, each tailored to a specific population. The NRHM addresses the healthcare needs of rural India, particularly in 18 states identified as having weak public health indicators, along with Empowered Action Group states, North Eastern States, Jammu and Kashmir, and Himachal Pradesh. The NUHM, on the other hand, focuses on the urban poor, especially slum dwellers, whose access to quality primary healthcare has historically been limited despite living close to large hospitals.

The mission was further extended in March 2018 and has been continued through subsequent approvals to maintain its ongoing work across the country.

Core components of NHM 🔗

The main programmatic components of the NHM include Health System Strengthening, Reproductive-Maternal-Neonatal-Child and Adolescent Health (RMNCH+A), and the control of both communicable and non-communicable diseases. These pillars are designed to work together rather than as isolated vertical programmes.

RMNCH+A: A continuum of care 🔗

The RMNCH+A strategy was launched in 2013 following the National Summit on Call to Action for Child Survival and Development. The ‘Plus’ in its name signals three important shifts in approach: including adolescence as a distinct life stage, linking maternal and child health with reproductive health and family planning, and creating continuous care pathways between community-based services and facility-based care.

The strategy is built on the concept of continuum of care, recognising that health interventions during one stage of life directly affect outcomes in the next. A well-nourished adolescent girl, for example, is more likely to have a healthy pregnancy later, which in turn improves the survival and growth of her child. According to a published analysis, the strategy specifically targeted 184 high-priority districts that historically performed poorly on key health indicators, ensuring that resources reached the geographies that needed them most.

The ASHA programme 🔗

Few interventions under NHM have been as transformative as the Accredited Social Health Activist, or ASHA. ASHAs are women selected from within their own communities, trained to act as the first point of contact between families and the public health system. They build trust in places where formal healthcare facilities are distant or unfamiliar.

Their work spans health education, helping pregnant women access antenatal checkups, encouraging institutional deliveries, mobilising children for immunisation, distributing iron tablets, and reporting disease outbreaks. More than 10 lakh ASHAs and ASHA facilitators are currently engaged under NHM, making it the largest community health volunteer programme in the world. For many families in remote villages, an ASHA is the single most accessible representative of the health system.

Anaemia Mukt Bharat and the National Iron Plus Initiative 🔗

Anaemia continues to affect a staggering share of Indians, especially women and children. National Family Health Survey 5 data shows that 57 percent of women aged 15-49 and 67.1 percent of children aged 6-59 months are anaemic. To address this, the National Iron Plus Initiative was strengthened in 2018 into the Anaemia Mukt Bharat strategy, which adopts a life-cycle approach through what is called the 6x6x6 framework: six beneficiary groups, six interventions, and six institutional mechanisms.

The beneficiary groups include children aged 6-59 months, children aged 5-9 years, adolescents aged 10-19 years, pregnant and lactating women, and women of reproductive age. The interventions cover prophylactic iron and folic acid supplementation, deworming, intensified behaviour change communication, testing and treatment of anaemia, addressing non-nutritional causes such as malaria and fluorosis, and providing iron-folate fortified foods in public health programmes.

Janani Suraksha Yojana and Janani Shishu Suraksha Karyakram 🔗

Two flagship initiatives under NHM have specifically tackled the financial barriers that kept poor women away from institutional childbirth. Janani Suraksha Yojana (JSY), launched in 2005, provides cash assistance to encourage pregnant women from low-income families to deliver in health facilities rather than at home. Janani Shishu Suraksha Karyakram (JSSK) goes further by offering free delivery, including caesarean section, free drugs, diagnostics, blood, diet, and transport for pregnant women and sick infants up to one year of age accessing public health institutions.

These entitlements have meaningfully reduced out-of-pocket expenditure for poor families during one of the most financially vulnerable moments in their lives.

Financial grants and infrastructure development 🔗

NHM follows a cooperative federalism approach. The Centre transfers funds to states through approved Programme Implementation Plans (PIPs), which are state-specific roadmaps spelling out activities, budgetary requirements, and expected outcomes. State PIPs are appraised by the National Programme Coordination Committee and approved by the Union Secretary of Health and Family Welfare.

This funding has been used to upgrade Primary Health Centres (PHCs) and Community Health Centres (CHCs), establish Health and Wellness Centres at the grassroots level, and build referral linkages with district hospitals. The mission also funds the recruitment of contractual doctors, nurses, ANMs, specialists, and public health managers, helping bridge the chronic shortage of health workers in underserved regions. Additional initiatives such as the Free Drugs Service Initiative and Free Diagnostics Service Initiative address the fact that nearly 70 percent of out-of-pocket health spending in India is on medicines and tests.

Other notable initiatives 🔗

NHM includes several initiatives that often go unnoticed but make a real difference. Mission Indradhanush targets children who have been left out of routine immunisation. The Kayakalp initiative awards public health facilities for cleanliness, infection control, and effective waste management. The National Ambulance Services, commonly known as 108 in many states, ensures emergency transport, while Rashtriya Bal Swasthya Karyakram (RBSK) screens children for the 4Ds – defects at birth, deficiencies, diseases, and development delays.

Impact on public health 🔗

The cumulative impact of NHM is best understood through changes in India’s most important health indicators. Over its years of implementation, the mission has helped India achieve significant declines in maternal, newborn, and child health indicators, with the rate of decline in India exceeding global averages and accelerating during the period of NHM implementation.

The Maternal Mortality Ratio dropped from 374 per 100,000 live births in 2001-03 to 113 per 100,000 live births in 2016-18 according to the Sample Registration System. The under-five mortality rate fell from 74 per 1,000 live births in 2012 to 37 per 1,000 live births in 2021. Vaccination coverage has expanded substantially, and India was certified polio-free in 2014 following sustained vaccination efforts supported through NHM.

Disease control progress 🔗

NHM has also driven measurable progress against communicable diseases. Programmes for tuberculosis, malaria, leprosy, vector-borne diseases, and HIV have been strengthened through the umbrella of the mission. India has set an ambitious target to eliminate tuberculosis by 2025 through intensified case finding and treatment, and malaria cases have declined sharply over the past two decades due to insecticide-treated nets and indoor residual spraying. Increasing attention is now being directed at non-communicable diseases such as diabetes, hypertension, cardiovascular illnesses, and cancers, reflecting India’s changing disease profile.

Healthcare access and equity 🔗

Perhaps the most quiet but lasting contribution of NHM has been the expansion of healthcare access for populations that were once invisible to the system. Tribal communities, urban slum residents, and women in conservative households now have channels to reach formal care, often through an ASHA, an ANM, or a sub-centre that simply did not function before. Health and Wellness Centres have brought comprehensive primary care closer to where people live, offering services for chronic illnesses, mental health, and palliative care in addition to maternal and child health.

Challenges that remain 🔗

Despite its achievements, NHM continues to face real challenges. Shortages of specialist doctors persist in rural and tribal areas. ASHAs, who carry enormous responsibility, are still classified as volunteers and receive performance-linked incentives rather than salaries, raising ongoing questions about their working conditions. Non-communicable diseases are rising faster than the system can adapt, and inter-state disparities in implementation remain significant. The mission’s success ultimately depends on continued political commitment, sustained financing, and the ability of states to translate national frameworks into responsive local action.

What do you think? If you were redesigning the NHM for the next decade, which area would you prioritise the most – strengthening the ASHA workforce, tackling non-communicable diseases, or closing the rural-urban gap in healthcare quality? And how should India balance the push for universal coverage with the need to deliver high-quality care?

References

1. https://nhm.gov.in/index4.php?lang=1&level=0&linkid=445&lid=38
2. https://nhm.gov.in/images/pdf/RMNCH+A/RMNCH+A_Strategy.pdf
3. https://pmc.ncbi.nlm.nih.gov/articles/PMC6509590/
4. https://www.drishtiias.com/daily-news-analysis/national-health-mission-1
5. https://www.pib.gov.in/PressReleasePage.aspx?PRID=1795421
6. https://nhm.gov.in/index1.php?lang=1&level=3&sublinkid=1448&lid=797
7. https://testbook.com/ias-preparation/national-health-mission